New Account Application

Company Name*

How did you hear about SOLO?*

Internet Search

Referral

I was a previous customer

Other

Who Referred You?

How will you most often capture the dimensions of your patients' feet?*

iPad / iPhone Scanner

Casts / STS Socks

Foam

SOLO recommends scanning for the most efficient ordering experience.

Billing Address*

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address Same as Billing

Shipping Address (if different from billing)

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accounting Contact

Name*

First Last

Email (required)

Enter Email Confirm Email

Phone (required)

Clinical Contact Same as Accounting

Clinical Contact

Name

First Last

Phone

Notifications

Would you like email notifications when Customer Service has questions about your orders?

Yes

CS Questions Email

Would you like email notifications when your orders ship?

Yes

Shipment Notification Email

Invoices

I prefer to receive my invoices by:*

Enclose with the order

Do you need separate invoices for each patient?*

Yes

Purchase Orders

Do you require Purchase Orders?*

Yes

Blanket PO #

Payment

How will you pay your invoices?*

ACH (recommended)

Credit Card

Net 30 (upon credit approval)

ACH Information

This field is hidden when viewing the form

Would you like to automatically pay your invoices via ACH?

Yes

ACH AGREEMENT POLICY For the convenience of our customers, SOLO Laboratories, Inc. accepts ACH payments for services rendered. By selecting this option, you agree that:

The outstanding balance for your account will be withdrawn by ACH on the 15th or 30th day of each month, as designated by the customer.
You will notify SOLO Laboratories, Inc. if there are any changes to the information on file.
There is a $5.00 processing fee, per transaction, if the ACH is processed manually and not on a monthly recurrent schedule.

ACH Account Name

Routing Number

Account Number

Payment Date

15th

30th

Credit Card Information

This field is hidden when viewing the form

Would you like to automatically pay your invoices with a credit card?

Yes

CREDIT CARD AGREEMENT POLICY For the convenience of our customers, SOLO Laboratories, Inc. accepts ACH payments for services rendered. By selecting this option, you agree that:

Credit cards are automatically charged as each shipment is made.
All previous balances will be added to the credit card.
You will notify SOLO Laboratories, Inc. if there are any changes to the information on file.
There is a $5.00 processing fee, per transaction, if the credit card is processed manually and not as orders are shipped.

Name on Card

Card Number

Expiration Date

Credit Card Billing Address Same as Main Billing Address

Credit Card Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Has the company, or any of its principals, ever had a judgement filed against it/them, or been insolvent or bankrupt?*

Yes

Please explain, in detail, whom the judgements were against or who was declared insolvent or bankrupt, including docket numbers and dates.

Signature

Name*

Title*

Date*

Note: Application must be submitted by owner/principal for credit consideration. The undersigned grants permission to SOLO Laboratories Inc. to access any credit information available on their company and/or principals in order to establish a credit account. All credit information will be available for review by the company if so requested in writing. All information is held in the strictest confidence. By signing this application the undersigned acknowledges: that all information supplied is true and correct to the best of your knowledge, that you understand our terms for payment of invoices, that you agree to pay 1.5% per month service charge if payment is received more than 30 days from the invoice date, that you are authorized to accept these terms on behalf of the company named herein, that a facsimile of this form and your signature carry the same weight and force as an original signature, Applicant agrees that if accounts are not promptly paid when due, the Applicant’s name may be listed in any collection or credit rating file. If Applicant’s account is referred to collection to any attorney or agency, Applicant will pay reasonable attorney fees of FIFTEEN PERCENT (15%) of the sum owed or FIVE HUNDRED DOLLARS ($500.00) , whichever is greater and costs of collection. Applicant agrees to pay a THIRTY DOLLAR ($30.00) fee for each returned check, rejected ACH or rejected credit approved credit for the Applicant, advance payments may be required.

This field is for validation purposes and should be left unchanged.

New Account Application